Rural Health Care Gets Boost From Innovative State/Federal Program

Before he started medical school, Peter Marshall pictured himself as a surgeon.

“We had a family friend who was a surgeon. He introduced me to medicine and I worked for him in the summers,” he said.

Then one day while Marshall was studying at the University of Missouri-Columbia School of Medicine, he attended a lecture by a family medicine doctor who worked in a rural area.

“He was telling stories about working in that environment, and how you can make such a difference in the community,” he said.

The work was varied — delivering babies, doing minor surgical procedures, and treating children, the elderly and anyone who needed his care. “It stuck with me. I thought, ‘I can do that.’”

Fast forward eight years, and that’s exactly what Dr. Marshall is doing in Pagosa Springs. He landed there at least in part because of the Colorado Health Service Corps, which places health care professionals in medically underserved communities and provides tax-free loan repayment plans as part of the compensation.

Pagosa, as the locals call it, is 35 miles north of the New Mexico border and is nearly surrounded by the San Juan National Forest and the Weminuche Wilderness Area. It makes the community attractive to outdoors enthusiasts, but all that wild land on its outskirts means it’s isolated from urban amenities – including shopping, entertainment options and comprehensive health care facilities.

State program expanding

The Colorado Health Service Corps has grown dramatically from a program that contracted with four to six health care providers a year for the past 20 years to one that will contract with about 100 in 2011.

“The state program has always been fairly modest,” said Stephen Holloway, director of the primary care office of the state Department of Public Health and Environment. “It used to be less than $150,000 a year. In 2011, we expect to grant about $3.8 million, so it’s a significant expansion.”

The growth was made possible by an innovative public-private partnership and an infusion of federal matching funds under the Affordable Care Act, Holloway said. “It occurred to me a couple years ago that really any source of non-federal dollars could be used for the federal match.”

So he developed relationships with the major health foundations in Colorado, including the Colorado Health Foundation, the Colorado Trust and the Comprecare Foundation, to boost the state investment. The state budget includes $120,000 a year for the loan repayment program.

Despite the growth of the program, Holloway said the need for health care providers across the state remains acute.

“About 85 percent of the land area (including areas in 54 of 64 counties) of Colorado is a designated health care provider shortage area.”

Those are anything but random designations. To be determined a health care provider shortage area, a region is found to have insufficient providers to meet even minimal standards of care. “The standards are pretty high,” he said.

A typical family practice physician in, say, Douglas County would serve about 1,500 patients, Holloway said. In contrast, to be designated an underserved community, generally the ratio of doctors to patients is one to 3,000 or 3,500.

In addition to physicians, the program also provides for placement of dentists, dental hygienists, nurse practitioners, physicians assistants, psychologists, social workers, psychiatric nurse specialists, licensed professional counselors and certified nurse midwives.

House Bill 1281 would expand the program to provide student loan forgiveness to qualified nursing faculty members who would agree to provide nursing education programs in medically underserved areas in the state.

The primary regions of Colorado that are not designated underserved, Holloway said, are the Front Range urban areas and the resort towns in the mountains. The areas with the most acute needs are in the San Luis Valley, the southeastern plains and portions of Adams County near Commerce City.

Opportunities benefit young providers

While people in the rural underserved areas look at the Health Service Corps program literally as a life-saver, for many health care providers entering the field with six-figure student loan debts, it can mean the difference between eking out a living until their debts are retired, and being able to buy a house and start a family.

“It’s a pretty enticing deal,” said Marshall. “It doesn’t completely wipe out my loans from medical school, but the vast majority will be wiped out.” Marshall was eligible for $35,000 in medical loan reimbursement a year for three years under his contract. His total student loan debt was in excess of $125,000.

Holloway said the maximum benefit is $50,000 of loan reimbursement per year for three years. The average cost of a physician’s education is $150,000 to $200,000, he said, “which is like having a mortgage.” It’s a key reason why medical students gravitate to high-paying specialties, such as dermatology or orthopedic surgery, and away from primary care medicine.

“A family practice provider generally makes $130,000 or $140,000 a year compared to $400,000 for a general surgeon,” Holloway said, so it takes a lot longer for a primary care doc to retire those debts.

DO & MD – Doctors of Osteopathic or Allopathic Medicine (family medicine, geriatrics, general internal medicine, general psychiatry, general child psychiatry, general pediatrics, and general obstetrics/gynecology)

LCSW – Licensed Clinical Social Workers (master’s or doctoral degree in social work)

LPC – Licensed Professional Counselors (master’s or doctoral degree with a major study in counseling)

MFT – Marriage and Family Therapists (master’s or doctoral degree with a major study in marriage and family therapy)

NP – Primary Care Certified Nurse Practitioners

PA – Primary Care Physician Assistants

PNS – Psychiatric Nurse Specialists

RDH – Registered Dental Hygienists

Long-term commitment the goal

The Health Service Corps is not satisfied with merely placing health care providers in underserved areas for three-year stints. “We actively try to work against that,” said Holloway.

The program managers try to recruit health care providers who are likely to put down roots in the rural communities and stay there. They look for applicants who grew up in Colorado or got their training here; persons who may have experienced life in an underserved community; or those who demonstrate a passion for serving low-income clients. Then they maintain close contact to resolve problems that might arise.

When a physician in a rural area faces challenges like a tremendous on-call burden, long hours and a really broad scope of care, “there’s a risk of burnout,” said Holloway. “We try to anticipate that and if we detect a challenge, we look at ways to strengthen the professional network or find educational opportunities to ease the stress.

At the same time, they work to attract and cultivate good employers for the Health Service Corps providers. Among the factors that can keep health care workers in communities after the three-year contracts are whether a spouse was able to find a job, if their children are happily incorporated into the community and whether the provider has support from colleagues and other medical professionals.

Holloway said the program surveys providers as they begin, during the middle of their service and when they leave. He plans to add surveys in the fifth year to determine why health care workers stay in underserved communities.

Making the Health Service Corps work will be a high priority as the Affordable Care Act is implemented. “If we assume that health care reform is going to stay on track over the next five years … we expect to see a bulge of new demand for care,” Holloway said.

Many of the previously uninsured people have chronic conditions that will need extra attention.

Commitment a personal decision

Peter Marshall said he’s enjoying the experience in Pagosa Springs, but he is trying to be thoughtful about his career. His workload is intense with about 60 hours a week spent seeing patients at the clinic at Pagosa Springs Medical Center plus rounds at the hospital there. But the environment has a lot of appeal.

“When I have time off, I enjoy being outside,” he said. “I find it recharging and rejuvenating. Hopefully things will work out and I’ll end up being in Pagosa a long time.”

Marshall’s wife, a nurse, works part time at the small hospital in Pagosa Springs and picks up additional work at the hospital in Durango, about an hour away.

Marshall grew up in Missouri, but did his undergraduate work in Colorado where he got hooked on the outdoor lifestyle here. He returned to the state to do his residency and, when the opportunity arose to move to Pagosa Springs and retire his student-loan debt, he and his wife took the leap.

“We both like it here. It’s a really pleasant community. People are really appreciative that a younger couple would come to a small town and settle down,” Marshall said.

That appreciation alone is worth a great deal to the young physician. “When it comes to a career, it’s a lot different from clustering in the city and competing with other doctors for business.”

In Pagosa, he’s a familiar face around town.

“It happens a few times a week, people come up to me and say, ‘Thank you for coming here.’ They really worry that they won’t have medical care close by,” he said.